DOI: 10.1097/01.sla.0000138625.29700.24
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Issn Print: 0003-4932
Publication Date: 2004/09/01
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Excerpt
The definition of nosocomial infection is based on Centers for Disease Control and Prevention recommendations. Even if this limit of 48 hours is somehow arbitrary, it is used worldwide, and there is currently no specific definition available for patients admitted in medical care facilities and who develop intra-abdominal complications.
We assume that acute abdominal complications in medical patients do not automatically lead to suspicion of a medical error and misdiagnosis but are a frequent and insufficiently assessed entity. In other words, timing of surgery is not the only point to consider to classify these patients. Obviously, some cases could have been identified lately after their admission as having intra-abdominal infection. However, it is hard to believe that all of our 247 patients were misdiagnosed and neglected.
The French guidelines recommend 1 single dose of empiric antibiotic treatment in patients suspected of having intra-abdominal infection before a surgical procedure and extensive microbiologic samples before treatment in other cases.1 We completely reject the hypothesis of misdiagnosed patients admitted in medical wards receiving empiric antibiotic treatment over a prolonged period of time and secondarily identified as surgical cases.
As mentioned in the “Results” section, three fourths of the “nosocomial” patients were transferred from another ward or another hospital in a mean delay of 4 ± 5 days after admission and underwent surgery in a mean delay of 1.3 ± 1.5 days after admission in the surgical ward. Based on Dr. Schein's assumption, the sum of all these delays would have led to surgery performed more than 5 days after admission (and intra-abdominal infection) in many cases. In this setting, a dramatic increase in mortality would have been expected with fatality rates growing up to more than 50%.2,3
Patients with an “open abdomen” procedure were not eligible in this survey, because we assume that it is rarely performed in such patients (except in the case of abdominal compartment syndrome) and an unusual technique in our country. In addition, in microbiologic terms, this procedure could be a factor of confusion. Indeed, contamination of microbiologic samples in this setting could interfere with our microbiologic analysis of the subpopulations. In addition, French guidelines do not recommend this technique, even for the sickest patients.1
The fact that clinical and microbiologic characteristics and antibiotic therapy could be similar in community-acquired intra-abdominal infections and nonpostoperative nosocomial intra-abdominal infections does not preclude that these diseases are a sole entity. Indeed, severe community-acquired pneumonia and early-onset (<5 days) nosocomial pneumonia share the same clinical and microbiologic characteristics and are treated with the same antibiotic regimens. However, nobody discusses the fact that these diseases are 2 distinct entities.4,5
Our study was not based on the manipulations of a database. The survey was clearly prospective, specifically designed to study the population of nonpostoperative intra-abdominal infections. All 176 study centers strictly followed the protocol and all eligible patients were prospectively diagnosed, treated, and followed up. No patients at all were evaluated on a retrospective basis. If this study has some limitations, they are those of all epidemiologic studies and we do not pretend to provide the same strength of evidence as a clinical trial. However, a carefully conducted cohort study gives a clear description of a population usually not identified in antimicrobial trials.
In conclusion, we did not intend to add confusion in the mind of attending physicians, but to bring them additional information on the management of what we assume to be a not-unusual disease with specific issues.
